IJG-08136; No of Pages 4

International Journal of Gynecology and Obstetrics xxx (2014) xxxxxx

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Maternity care provider knowledge, attitudes, and practices regarding

provision of postpartum intrauterine contraceptive devices at a tertiary
center in Ghana
Devon M. Rupley a,, Emmanuel S.K. Morhe b, Cheryl A. Moyer c, Vanessa K. Dalton d
a

Department of Obstetrics and Gynecology, New York Presbyterian/Columbia University Medical Center, New York City, NY, USA
Department of Obstetrics and Gynaecology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
c
Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
d
Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
b

a r t i c l e

i n f o

Article history:
Received 21 April 2014
Received in revised form 30 August 2014
Accepted 21 October 2014
Keywords:
Contraceptive counseling
Intrauterine device
Postpartum contraception
Training

a b s t r a c t
Objective: To assess knowledge, attitudes, and practices of maternity care providers regarding the provision of
postpartum intrauterine contraceptive devices (IUDs) in Komfo Anokye Teaching Hospital (KATH), Kumasi,
Ghana. Methods: A descriptive, cross-sectional study was conducted between June 28 and July 15, 2011.
Specialists, residents, house ofcers, and nurse midwives who had been working in the Department of Obstetrics
and Gynecology for at least 3 months were included. Self-administered questionnaires assessed formal training,
current prociency in IUD insertion, and attitudes toward postpartum IUD provision. Results: Of 91 providers surveyed, 70 (77%) reported previous training in contraceptive counseling. Fewer than one in three respondents had
ever inserted an IUD: 17 (44%) of 39 physicians and 9 (17%) of 52 midwives reported ever having inserted an IUD.
A total of 33 (36%) respondents reported that they would recommend an IUD in the immediate postpartum
period. Conclusion: Although most maternity care providers at KATH had received training in contraceptive
counseling, few felt condent in their ability to insert an IUD. Further training in postpartum contraceptive
management is needed.
2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The West African nation of Ghana has a national reproductive
health policy with clearly dened targets, standards, and protocols [1].
However, the contraceptive needs of many women in the country
remain unmet, especially in the period immediately after delivery
[13]. In 2003, only 19.3% of married women reported current use of
any modern contraceptive method [2]. Low contraceptive use has
been associated with high numbers of unwanted pregnancies, unintended births, and unsafe abortions, which are in turn linked to high
maternal and child morbidity and mortality [4,5].
The Copper T 380A intrauterine contraceptive device (IUD) is a safe
and effective reversible contraceptive that provides 10 years of protection against pregnancy. Furthermore, it can be inserted in the immediate postpartum period [6,7]. However, less than 1% of women in
Ghana used the Copper T IUD [2]. The low use could be partly due to
provider and institutional factors that affect the contraceptive-seeking
behavior of women [8]. In recent surveys in South Africa [9,10], family

Corresponding author at: 622 West 168th St., Suite 1629, New York, NY 10032, USA.
Tel.: +1 248 345 2570; fax: +1 212 305 4672.
E-mail address: dr2777@cumc.columbia.edu (D.M. Rupley).

planning providers were found to have poor knowledge about IUDs

and to hold incorrect beliefs about IUD risks and client selection.
The immediate postpartum period is an opportune but underused
time to counsel women on contraceptive options to prevent future unwanted pregnancies. Effective client education and improvements in access to services could address many perceived barriers to contraceptive
uptake in this period [11]. Provider prociency in carrying out comprehensive education and counseling on postpartum contraception is particularly important in settings where literacy rates are low [12]. In a
systematic review, Lopez et al. [13] indicated that education on postpartum contraceptive use is associated with increased contraception use
and a reduction in the occurrence of unplanned pregnancies. They further found that both short-term and multiple-contact educational interventions had positive effects on rates of postpartum contraceptive use
[13]. These ndings underscore the importance of judicious use of the
postpartum period as an opportunity to expose women to comprehensive contraceptive information as well as making the method of their
choice available to them.
In Ghana, in addition to ensuring healthy infant growth from exclusive breastfeeding, lactational amenorrhea is often promoted as a means
of birth control within the rst 6 months post partum. Postpartum contraceptives are also offered, including long-acting reversible and permanent methods. Although not free, most contraceptives (including IUDs)

http://dx.doi.org/10.1016/j.ijgo.2014.09.010
0020-7292/ 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Rupley DM, et al, Maternity care provider knowledge, attitudes, and practices regarding provision of postpartum
intrauterine contraceptive devices a..., Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.09.010

D.M. Rupley et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxxxxx

are generally available at heavily subsidized cost in public and private

health institutions. Contraceptive services in Ghana are largely provided
by midwives and public health nurses. Physicians, particularly maternity care providers, also take part in contraceptive counseling and education in addition to providing surgical methods of birth control.
The present study was developed to guide the design and implementation of an intervention project to improve postpartum contraceptive service delivery of IUDs in the Komfo Anokye Teaching Hospital
(KATH). Its aim was to determine the proportion of maternity care providers who have been trained in contraceptive counseling regarding
IUDs, felt condent inserting an IUD, and would recommend immediate
postpartum IUD insertion. Additionally, provider knowledge about client selection and risks for IUD use were assessed.

2. Materials and methods

A descriptive, cross-sectional survey of maternity care providers was
conducted at KATH between June 28 and July 15, 2011. KATH is the
second largest tertiary care center in Ghana, and is the training and research center for the College of Health Sciences of the Kwame Nkrumah
University of Science and Technology in Kumasi, Ghana. The Department
of Obstetrics and Gynecology trains residents, medical students,
midwives, nurses, and paramedics, among others. The department has
a busy antenatal clinic and oversees more than 1200 deliveries annually.
Specialist obstetricians and gynecologists, residents, house ofcers, and
nurse midwives who had been working in the Department of Obstetrics
and Gynecology for at least 3 months were eligible to participate in the
present study. The study was reviewed and approved by the University
of Michigan and Kwame Nkrumah University institutional review
boards. Verbal consent was obtained from all participants.
Eligible maternity care providers were contacted by a member of
study team while on duty in various units of the department. A printed
questionnaire was distributed for self-administration. Individuals had
the option to abstain from participating in the study. Completed surveys
were placed in a folder and collected from providers by a team member.
Once participants completed the questionnaire, contact was not maintained individually. Anonymity was ensured and no specic identiers
were obtained during the survey; questionnaires could not be traced
to the participants.
Survey items addressed the respondents exposure to training and
current prociency in offering IUD services, their attitudes toward postpartum IUD service provision, and recommendation of IUD for different
subpopulations of patients. Provider willingness to recommend the use
of IUDs for specic subgroups was explored, including women in the immediate postabortion period, nulliparous women, teenagers, women
with a history of ectopic pregnancy, women with history of sexually
transmitted infection or pelvic inammatory disease in the last 2 years,
women with bacterial vaginosis, and women with HIV infection.
The main outcome measures were the percentage of providers who
had been trained and felt condent in offering postpartum contraceptive counseling services and the proportion who would recommend
IUDs for different subpopulations of maternity clients. The results of
the present study were presented to physicians and midwives of the Department of Obstetrics and Gynecology, and the ndings and suggestions were incorporated into the design of the intervention project to
improve postpartum IUD service delivery in KATH.
The sample size was calculated with 95% condence intervals and 5%
condence limits, and was determined to be 132 on the basis of the hypothesis that 50% of providers had been trained and would readily recommend immediate postpartum contraception. Data were entered into
Microsoft Excel (Microsoft Inc, Redmond, WA, USA) and then imported
into SPSS version 15.0 (SPSS Inc, Chicago, IL, USA) for analysis. In view of
the exploratory nature of the present study, calculated statistics were
mostly descriptive. When appropriate, Pearson 2 and ANOVA statistics
were used to evaluate differences in opinions of physicians and

midwives on IUD insertion in specic subpopulations of clients.

P 0.05 was considered signicant.
3. Results
Approximately 200 maternity care providers were eligible to participate, although exact numbers are unknown because residents and
midwives rotate through several different sites during training. Approximately one-third of these providers were physicians. A total of 140 surveys were distributed, 91 (65%) of which were completed after surveys
from ineligible providers were excluded. In all, 39 physicians and 52 midwives completed surveys. Table 1 shows their characteristics.
Of the 91 maternity care providers surveyed, more than threequarters had received some training in contraceptive counseling
(Table 1). Slightly more than half the respondents reported that they
felt comfortable counseling clients on contraception, including almost
60% of midwives (Table 1). More than 90% of providers discussed
IUDs only occasionally or not all during prenatal or postpartum care
(Table 1). Overall, less than one-third of providers had ever inserted
an IUD, with fewer midwives than physicians reporting previous
insertion (Table 1).
Regarding immediate postpartum IUD placement, 33 (36%) respondents thought it was safe to insert an IUD in the immediate postpartum
period, including 16 (41%) of 39 physicians and 17 (33%) of 52 midwives (2 = 2.89; P = 0.09). Conversely, almost all respondents
would recommend IUD insertion after 6 weeks post partum (Table 2).
Almost half the respondents would not recommend IUD placement
to nulliparous women or to teenagers (Table 2). More than half the physicians reported that they would recommend IUD insertion immediately after an abortion, compared with only one-third of midwives
(Table 2). Few providers reported that they would recommend IUDs
to women with a history of ectopic pregnancy or who had had a pelvic
inammatory disease within the previous 2 years (Table 2). Almost half
of respondents would recommend an IUD to a woman with HIV
(Table 2). Very few reported that they would recommend an IUD to a
woman with bacterial vaginosis (Table 2).
Table 1
Characteristics, experiences, and views of participants.a
Variables

Physicians
(n = 39)

Midwives
(n = 52)

Total
(n = 91)

Female
Male
Age, y
Mean SD
Median (range)
Length of service at KATH, y
Mean SD
Median (range)
Had training in contraception counseling
Yes
No
Felt condent counseling on
contraception
Yes
No
Discuss postpartum IUD use
Not at all
Occasionally
Frequently
Very frequently
Ever inserted IUD
Yes
No
Feel comfortable inserting IUDb
Yes
No

13 (33)
26 (67)

52 (100)
0

65 (71)
26 (29)

34.0 7.8
31 (2551)

37.3 13.8 35.9 11.7

29 (2260) 30 (2260)

4.1 4.7
2 (015)

7.9 10.1
3 (035)

6.3 8.3
30 (035)

31 (79)
8 (21)

39 (75)
13 (25)

70 (77)
21 (23)

18 (46)
21 (54)

30 (58)
22 (42)

48 (53)
43 (47)

10 (26)
25 (64)
3 (8)
1 (3)

4 (8)
45 (87)
2 (4)
1 (2)

14 (15)
70 (77)
5 (5)
2 (2)

17 (44)
22 (56)

9 (17)
43 (83)

26 (29)
65 (71)

13 (76)
4 (24)

5 (56)
4 (44)

18 (69)
8 (31)

Abbreviations: KATH, Komfo Anokye Teaching Hospital; IUD, intrauterine device.

a
Values are given as number (percentage) unless indicated otherwise.
b
Percentages calculated with the numbers of providers who had ever inserted an IUD.

Please cite this article as: Rupley DM, et al, Maternity care provider knowledge, attitudes, and practices regarding provision of postpartum
intrauterine contraceptive devices a..., Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.09.010

D.M. Rupley et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxxxxx
Table 2
Maternity care provider attitude toward recommending use of IUDs in specic
circumstances.a
Recommendations

Physicians
(n = 39)

Midwives
(n = 52)

Use in nulliparous women

Yes
22 (56)
27 (52)
No
17 (44)
25 (48)
Use in immediate postabortion period
Yes
22 (56)
17 (33)
No
17 (44)
35 (67)
Use in teenagers
Yes
17 (44)
30 (58)
No
22 (56)
22 (42)
Use in women with a previous ectopic pregnancy
Yes
12 (31)
2 (4)
No
27 (69)
50 (96)
Use in women who had had an STI within past 2 years
Yes
10 (26)
11 (21)
No
29 (74)
39 (75)
Unanswered
0
2 (4)
Use in women who had had pelvic inammatory disease within past 2
Yes
7 (18)
7 (13)
No
32 (82)
45 (87)
Use in women with HIV infection
Yes
21 (54)
21 (40)
No
18 (46)
31 (60)
Use in women with bacterial vaginosis
Yes
4 (10)
4 (8)
No
34 (87)
47 (90)
Unanswered
1 (3)
1 (2)
Use in immediate postpartum period
Yes
16 (41)
17 (33)
No
18 (46)
23 (44)
Unanswered
5 (13)
12 (23)
Use after 6 weeks post partum
Yes
37 (95)
49 (94)
No
2 (5)
3 (6)

Total
(n = 91)
49 (54)
42 (46)
39 (43)
52 (57)
47 (52)
44 (48)
14 (15)
77 (85)
21 (23)
68 (75)
2 (2)
years
14 (15)
77 (85)
42 (46)
49 (54)
8 (9)
81 (89)
2 (2)
33 (36)
41 (45)
17 (19)
86 (95)
5 (5)

Abbreviations: IUD, intrauterine device; STI, sexually transmitted infection.

a
Values are given as number (percentage).

4. Discussion
Although most (77%) maternity care providers surveyed at KATH in
the present study reported having had any training in contraceptive
counseling, only approximately half felt comfortable counseling individuals about contraception. More than 90% never or only occasionally
discussed use of IUDs in the postpartum period with clients. Most
respondents also held misconceptions about the use of IUDs in various
subpopulations. Perhaps most surprisingly, few respondents felt condent about inserting an IUD.
Provider bias regarding the appropriateness of IUD use among subpopulations of women continues to be a major barrier to IUD uptake.
Evidence indicates that IUDs are safe and well tolerated in nulliparous
women [14]. However, many healthcare providers have misconceptions
about the safety of an IUD in nulliparous women [14,15]. This observation is clearly supported by the present nding that half of maternity
care providers surveyed were unwilling to recommend the use of an
IUD to nulliparous women.
Furthermore, it is well established that IUD insertion immediately
after induced or spontaneous abortion is safe and practical [16,17].
Thus, the low willingness of the respondents to recommend IUD for
this subpopulation of women implies that most maternity care
providers in the department did not have up-to-date knowledge and
skill in provision of IUD services. The ndings of the present study also
support the observation that, despite evidence that IUD-associated
pelvic inammatory disease and sexually transmitted infections are
not prevalent in West Africa, many providers are not well informed
[18]. Many providers in the present study still held onto the misconception that use of IUDs in women with a history of sexually transmitted
infections or pelvic inammatory disease should be avoided. Notably,

the opinions and attitudes of physicians and midwives were similar.

Thus, in planning interventions, both physicians and midwives should
be targeted.
The present study has several limitations. We surveyed providers at
only one site and within one specialty; further study of providers at
other facilities throughout West Africa and in other specialties in
which contraception is discussed would provide a more accurate representation of knowledge and practices regarding IUDs in this region. Additionally, because of survey length constraints, the specic types of
training on IUDs previously received by providers could not be addressed. This area should be explored further at KATH and elsewhere
in the future.
The overall rate of counseling on immediate postpartum contraception and which other immediate postpartum contraceptive options
were being offered to patients were not assessed. This information
would provide a broader understanding of current contraceptive
counseling within the immediate postpartum period, and could help
to focus further provider training. Furthermore, the present study was
focused on providers only; additional studies of patient knowledge
and attitudes towards IUDs generally and in the immediate postpartum
period specically should be undertaken as the next step in determining
barriers to increasing use of long-acting reversible contraceptives in this
population. Finally, because of time and scheduling limitations, the desired sample size of 132 was not achieved; additional study participants
would increase the strength of the study.
In conclusion, the present studys ndings demonstrate gaps in the
knowledge and skill regarding provision of IUD services at KATH. These
gaps need to be addressed to enable providers to effectively educate
and serve clients who need postpartum family planning [19]. The data
support the call for interventions to improve provider knowledge, information, and skills through strengthening of both in-service and preservice education programs. Strengthening of preservice training in family
planning and regular updates to address misconceptions about IUDs
and other long-term contraceptives are needed. A short-term intervention to improve knowledge and skill of providers is needed at KATH.
Acknowledgments
An anonymous donor funded this project through the International
Family Planning Fellowship Program. The International Institute at the
University of Michigan also provided nancial support.
Conict of interest
V.K.D received funding from McNeil to participate in a one-time
advisory committee in December 2012. The other authors have no
conicts of interest.
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Please cite this article as: Rupley DM, et al, Maternity care provider knowledge, attitudes, and practices regarding provision of postpartum
intrauterine contraceptive devices a..., Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.09.010